When assessing a child after heart surgery to correct Tetralogy of Fallot (TOP) which finding should alert the nurse to suspect a le carat output?
Altered level of consciousness and treaty pulse
Bounding pulses and mottled skin
Capillary refill of 2 seconds and blood pressure of 96/47 mmHg
Extremities warm to the touch and pale skin
The Correct Answer is A
A.Altered level of consciousness and thready pulse.
In a child after heart surgery to correct Tetralogy of Fallot (TOF), a thready pulse and altered level of consciousness can be indicative of poor cardiac output. This may suggest that the heart is not effectively pumping blood to meet the body's needs.
B. Bounding pulses and mottled skin: Bounding pulses and mottled skin are not typical signs of decreased cardiac output. Bounding pulses are often associated with increased cardiac output.
C. Capillary refill of 2 seconds and blood pressure of 96/47 mmHg: A capillary refill of 2 seconds is within the normal range, and a blood pressure of 96/47 mmHg is reasonable for a child. These findings do not necessarily indicate poor cardiac output.
D. Extremities warm to the touch and pale skin: Warm extremities and pale skin are not typical signs of decreased cardiac output. Cold extremities and cyanosis may be more concerning signs.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
A. Positive Western blot test: A positive Western blot test confirms HIV infection but doesn't provide information about the current immune status or progression of the disease.
B. CD4-T-cell count 180 cells/mm³.
The CD4-T-cell count is a crucial indicator of a person's immune system function, and it's a primary marker used to monitor the progression of HIV infection. A CD4 count of 180 cells/mm³ is significantly below the normal range (which is typically higher), indicating immunosuppression and an increased risk of opportunistic infections. Maintaining and improving immune function is a top priority in the care of clients with HIV.
C. Platelets 150,000/mm³: Platelet counts are important, but they are not the primary indicator for assessing the progression of HIV.
D. WBC 5.000/mm³: The white blood cell count (WBC) is important for assessing overall immune function, but it doesn't provide the same specific information about the immune system status as the CD4-T-cell count.
Correct Answer is A
Explanation
A. Praise them for the care they are giving their child.
Families facing the impending loss of a child need compassion and support. Praising them for the care they are giving their child acknowledges their efforts and reinforces their role in providing comfort to the child. This can help build trust and rapport between the family and healthcare providers during this difficult time.
B. Informing the family that they should have taken better care of their child is judgmental and hurtful. It does not provide the emotional support the family needs.
C. Telling the family to wait until after the death to discuss feelings is not helpful. Open communication and addressing feelings should be encouraged throughout the process.
D. Telling them that the staff will perform all of the final care may come across as impersonal. Involving the family in the care of their dying child can be an important part of the grieving and healing process.
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